Groundhog Day and Allergies – misadventures in bad news delivery.

Treating patients with cancer is not a funny business, but sometimes funny (odd) things happen.  Early on in my career I had a patient I was about to see with a very curable cancer.  I was suffering from seasonal allergies at the time, and entered the room with my eyes watering, blowing my nose, and looking like sh@t.  The patient also had her eyes watering, was blowing her nose, and looked like she was having a hard time.  In my self-absorbedness I asked her “Oh, do you have allergies too?”.  She looked at me like I was from Mars and said “No, Cancer”.  There was an awkward pause as I apologized, and then we both had a good laugh at my faux pas.  Not the icebreaker I generally use, but it did ease the tension and relaxed everybody…

One of my other memorable patients had a very bad cancer – pancreatic cancer, which he was going to die from at some point.  He was simple – picture Forrest Gump simple – and tolerated chemotherapy really well which held his disease at bay for several months with good quality of life.  However, everytime I saw him, we’d have the same conversation.  “Doc, I’m doing well, but be honest, pancreatic cancer isn’t good is it?  I’m probably going to die from this?”.  For the first few times, I answered him honestly – “I’m sorry, but yes this cancer will get worse at some point and you are very likely to die from this”.  He would then break down and cry unconsolably for the next five to ten minutes, and then suddenly stop, feel better, and be chipper and positive once again.  The amazing thing was that every four weeks when I saw him it was the same – it felt like Groundhog Day.

After the first several times, when I realized that this wasn’t a matter of repeating things so that he would eventually come to terms with it, I stopped answering him directly – in general I’m a doctor who when asked a direct question will give a direct answer.  However, with him, I didn’t think I was offering any therapeutic benefit by answering his question, and instead would redirect and give a political answer..  It probably didn’t affect him one way or another, but it saved me from the devastating feeling you get as a physician when your patient is devastated with bad news.

The point of this – rather extreme example – is that there is a widespread belief that oncologists don’t discuss prognosis with their patients, or that patients are somehow misinformed.  If this patient would have went to see another doctor – like an emergency room physician, there is no question that they would have said “No, I have no idea what’s going to happen”, and the ER doc would say “Damn oncologists, they never talk to their patients about prognosis”.